Client Enrollment & Authorization – 30-Day Advocacy Service
Begin your 30-day billing advocacy engagement with Our Helping Hands (OHH) Health Solutions. Please provide complete and accurate information to enable us to advocate on your behalf.
CLIENT & PATIENT INFORMATION
Tell us who is requesting advocacy and who the patient is.
Full Name of Person Completing This Form
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address (primary communication & updates)
*
example@example.com
Are you the patient involved in this billing issue?
*
Yes
No
Patient Full Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Relationship to Patient
*
Please Select
Spouse
Parent/Guardian
Child
Other
PRIMARY CONTACT & COMMUNICATION
Who should OHH contact for updates and decisions regarding this case?
Who should OHH contact for updates and decisions?
*
Person completing this form
Another authorized individual
Full Name (Primary Contact)
*
First Name
Last Name
Phone Number (Primary Contact)
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address (Primary Contact)
*
example@example.com
Preferred Method of Communication
*
Email
Phone
BILLING & PAYMENT RESPONSIBILITY
Who is financially responsible for this account?
Who is financially responsible for this account?
*
Patient
Family Member
Other (please specify)
Email address for invoices, receipts, and billing notices
*
example@example.com
I confirm that the billing responsibility information provided is accurate.
*
I confirm that the billing responsibility information provided is accurate.
BILLING ISSUE OVERVIEW
Provide details about the billing issue you need help with.
Provider / Hospital Name(s)
*
Type of Issue (select all that apply)
*
Incorrect charges
Duplicate billing
Insurance processing errors
Denied or underpaid claims
Collections involvement
Other (please specify)
Total Estimated Balance in Question (USD)
*
Has any appeal or dispute already been filed?
*
Yes
No
Not sure
DOCUMENT UPLOADS (REQUIRED)
Providing complete documentation allows advocacy work to begin without delay.
Upload Medical Bill(s) or Itemized Statement
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Upload Explanation of Benefits (EOBs)
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Upload Insurance Card (front & back)
*
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Upload prior correspondence with provider or insurance (if available)
Upload a File
Drag and drop files here
Choose a file
Cancel
of
AUTHORIZATION TO ADVOCATE
Authorization is essential for OHH to advocate on your behalf.
I authorize Our Helping Hands (OHH) Health Solutions to communicate with medical providers, insurance companies, and related entities on my behalf for the purpose of billing advocacy, corrections, and appeals related to this matter.
*
I authorize OHH to act as my billing advocate for this case
SERVICE SCOPE & EXPECTATIONS
Please review what is included in the 30-Day Advocacy Resolution service.
What the 30-Day Advocacy Resolution Includes:
• Direct phone calls to providers and insurance companies
• Active pursuit of billing corrections or adjustments
• Appeals and reconsiderations when appropriate
• Weekly status updates provided to the designated contact
• Documentation of actions taken during the advocacy period
Important Notes:
• This service covers up to 30 days of active advocacy
• Outcomes are not guaranteed
• Additional issues or extended advocacy may require a new agreement
I understand this is a 30-day advocacy service
*
I understand this is a 30-day advocacy service
I understand outcomes are not guaranteed
*
I understand outcomes are not guaranteed
I understand additional advocacy beyond 30 days requires a new agreement
*
I understand additional advocacy beyond 30 days requires a new agreement
WEEKLY UPDATE PREFERENCE
Let us know how you’d like to receive weekly updates during your service.
How would you like to receive weekly updates?
*
Email
Phone
Best day/time for updates (optional)
ELECTRONIC SIGNATURE & AGREEMENT
Please review and sign to begin advocacy services.
By signing below, I confirm that the information provided is accurate and I authorize Our Helping Hands (OHH) Health Solutions to begin advocacy services as described above.
Electronic Signature (Client or Authorized Representative)
*
Date
*
-
Month
-
Day
Year
Date
Submit Enrollment
Submit Enrollment
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